Extensively drug‐resistant tuberculosis (XDR‐TB) among health care workers in South Africa

Objective To determine the clinical profile and outcomes of health care workers (HCWs) with extensively drug resistant tuberculosis (XDR‐TB) in the Eastern and Western Cape Provinces of South Africa. Method Retrospective case record review of 334 patients with XDR‐TB reported during the period 1996–2008 from Western and Eastern Cape Province, Cape Town, South Africa. Case records of HCWs with XDR‐TB were analysed for clinical and microbiological features, and treatment outcomes. Results From 334 case records of patients with XDR‐TB, 10 HCWs were identified. Eight of ten were HIV‐uninfected, and four of 10 had died of XDR‐TB despite treatment. All 10 HCWs had received an average of 2.4 courses of TB treatment before being diagnosed as XDR‐TB. Conclusions In the Eastern and Western Cape provinces of South Africa XDR‐TB affects HCWs, is diagnosed rather late, does not appear to be related to HIV status and carries a high mortality. There is an urgent need for the South African government to implement WHO infection control recommendations and make available rapid drug susceptibility testing for HCWs with suspected multidrug‐resistant (MDR)/XDR‐TB. Further studies to establish the actual risk and sources of infection (nosocomial or community) are required.     

Review of multidrug‐resistant and extensively drug‐resistant TB: global perspectives with a focus on sub‐Saharan Africa

Tuberculosis (TB) remains a global emergency and is responsible for 1.7 million deaths annually. Widespread global misuse of isoniazid and rifampicin over three decades has resulted in emergence of the ominous spread of multidrug‐resistant TB (MDR‐TB) and extensively drug‐resistant TB (XDR‐TB) globally. These difficult to treat resistant forms of TB are increasingly seen in Asia, Eastern Europe, South America and sub‐Saharan Africa, disrupting TB and HIV control programmes. We review the latest available global epidemiological and clinical evidence on drug‐resistant TB in HIV‐infected and uninfected populations, with focus on Africa where data are scanty because of poor diagnostic and reporting facilities. The difficult management and infection control problems posed by drug‐resistant TB in HIV‐infected patients are discussed. Given the increasing current global trends in MDR‐TB, aggressive preventive and management strategies are urgently required to avoid disruption of global TB control efforts. The data suggest that existing interventions, public health systems and TB and HIV programmes must be strengthened significantly. Political and funder commitment is essential to curb the spread of drug‐resistant TB.     

Scale‐up of TB and HIV programme collaborative activities in Zambia – a 10‐year review

Objective To review the activities, progress, achievements and challenges of the Zambia Ministry of Health tuberculosis (TB)/HIV collaborative activities over the past decade. Methods Analysis of Zambia Ministry of Health National TB and HIV programme documents and external independent programme review reports pertaining to 2000–2010. Results The number of people testing for HIV increased from 37 557 persons in 2003 to 1 327 995 persons in 2010 nationally. Those receiving anti‐retroviral therapy (ART) increased from 143 in 2003 to 344 304 in 2010. The national HIV prevalence estimates declined from 14.3% in 2001 to 13.5% in 2009. The proportion of TB patients being tested for HIV increased from 22.6% in 2006 to 84% in 2010 and approximately 70% were HIV positive. The proportion of the HIV‐infected TB patients who: (i) started on ART increased from 38% in 2006 to 50% in 2010; (ii) commenced co‐trimoxazole preventive therapy (CPT) increased from 31% in 2006 to 70% in 2010; and (iii) were successfully treated increased to an average of 80% resulting in decline of deaths from 13% in 2006 to 9% in 2010. Conclusions The scale‐up of TB/HIV collaborative programme activities in Zambia has steadily increased over the past decade resulting in increased testing for TB and HIV, and anti‐retroviral (ARV) rollout with improved treatment outcomes among TB patients co‐infected with HIV. Getting service delivery points to adhere to WHO guidelines for collaborative TB/HIV activities remains problematic, especially those meant to reduce the burden of TB in people living with HIV/AIDS (PLWHA).     

Mortality in patients with community‐onset pneumonia at low risk of drug‐resistant pathogens: Impact of β‐lactam plus macrolide combination therapy

Background and objective

Drug‐resistant pathogen (DRP) risk stratification is important for choosing a treatment strategy for community‐onset pneumonia. Evidence for benefits of non‐antipseudomonal β‐lactam plus macrolide combination therapy (BLM) on mortality is limited in patients at low DRP risk. Risk factors for mortality remain to be clarified.

Methods

Post hoc analysis using a prospective multicentre study cohort of community‐onset pneumonia was performed to assess 30‐day differences in mortality between non‐antipseudomonal β‐lactam monotherapy (BL) and BLM groups. Logistic regression analysis was performed to assess the therapeutic effect and risk factors for mortality in patients at low DRP risk.

Results

In total, 594 patients with community‐onset pneumonia at low DRP risk (369 BL and 225 BLM) were analysed. The 30‐day mortality in BL and BLM was 13.8% and 1.8%, respectively (P < 0.001). Multivariate analysis showed that BLM reduced the 30‐day mortality (adjusted odds ratio: 0.28, 95% CI: 0.09–0.87) compared with BL. Independent prognostic factors for 30‐day mortality included arterial partial pressure of carbon dioxide (PaCO₂) > 50 mm Hg, white blood cell count < 4000/mm³, non‐ambulatory status, albumin < 3.0 g/dL, haematocrit < 30%, age ≥ 80 years, respiratory rate > 25/min and body temperature < 36°C.

Conclusion

In patients with community‐onset pneumonia at low DRP risk, BLM treatment reduced 30‐day mortality compared with BL. Independent risk factors for mortality are potential confounding factors when assessing antibiotic effects in randomized clinical trials.

     

Monitoring ivermectin distributors involved in integrated health care services through community‐directed interventions – a comparison of Cameroon and Uganda experiences over a period of three years (2004–2006)

Objectives To assess and compare the effectiveness of ivermectin distributors in attaining 90% treatment coverage of the eligible population with each additional health activity they take up. Methods Random sampling was applied every year to select distributors for interviews in community‐directed treatment with ivermectin (CDTI) areas of Cameroon and Uganda. A total of 288 in 2004, 357 in 2005 and 348 in 2006 distributors were interviewed in Cameroon, and 706, 618 and 789 in Uganda, respectively. The questions included treatment coverage, involvement in additional activities, where and for how long these activities were provided, and whether they were supervised. Results At least 70% of the distributors in Cameroon and Uganda during the study period were involved in CDTI and additional health activities. More of the distributors involved in CDTI alone attained 90% treatment coverage than those who had CDTI with additional health activities. The more the additional activities, the less likely the distributors were to attain 90% treatment coverage. In Uganda, distributors were more likely to attain 90% coverage (P < 0.001 if they worked within 1 km of their homesteads were selected by community members, worked among kindred, and were responsible for <20 households. Conclusion Additional activities could potentially undermine the performance of distributors. However, being selected by their community members, working largely among kindred and serving fewer households improved their effectiveness.